New York State Department of Health
Center for Environmental Health
Health Consultation
PUBLIC COMMENT DRAFT
Thyroid Condition Follow-Up Report,
Hickory Woods Subdivision,
City of Buffalo, Erie County, New York
April 2004
Prepared under a Cooperative Agreement with
U.S. Department of Health & Human Services
Public Health Service
Agency for Toxic Substances and Disease Registry
In an effort to reduce the costs of printing and postage,
please notify us if you wish your name to be deleted from
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New York State Department of Health
Center for Environmental Health
Outreach and Education Unit
Flanigan Square, Room 316
547 River Street
Troy, NY 12180
1-800-458-1158, Ext. 27530
(518) 402-7530
TABLE OF CONTENTS
BACKGROUND AND STATEMENT OF ISSUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
A. Additional Information about Exposure Survey conducted in 2000 . . . . . . . . . . .
2
B. Thyroid Condition Follow-up Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
C. Additional Information about Thyroid Disease Risk Factors . . . . . . . . . . . . . . . . .
4
D. Follow-up Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
RECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
PREPARERS OF THE REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
LIST OF ATTACHMENTS
Attachment 1
Attachment 2
Attachment 3
Attachment 4
Attachment 5
Attachment 6
Attachment 7
Summary of Hickory Woods Subdivision Exposure Survey Responses
Introduction Letter
Telephone Protocol
Thank-you Letter to Participants
Consent to Release Medical Information
Letter to Health Care Provider
Participant Interview Questions
BACKGROUND AND STATEMENT OF ISSUES
In response to concerns about potential exposures and health problems in the Hickory Woods
Development in Buffalo, New York, in December of 1999, the New York State Department of
Health (NYS DOH) proposed conducting an exposure survey in the community. The primary
purpose of the survey was to gather information about the people living at each residence,
whether they had noticed or come in contact with chemical substances or unusual materials in
the subdivision, and whether they had health concerns related to potential environmental
exposures. This information would be helpful for planning an appropriate health study, if the
environmental sampling results indicated that such a study was warranted. Although the primary
purpose of the exposure survey conducted in Hickory Woods in 2000 was to collect information
on potential exposures, the survey also provided residents with an opportunity to report health
problems that might suggest unusual patterns of illness in the neighborhood, if such patterns
existed.
Staff of the NYS DOH developed the draft survey and worked with representatives of the
Hickory Woods Concerned Homeowners’ Association, Citizen’s Environmental Coalition and
Environment and Society Institute of the University at Buffalo to revise the survey, draft a cover
letter about the purpose of the survey, and develop a plan for administering the survey. NYS
DOH sent copies of the survey to residents prior to contacting each household by telephone. The
survey was conducted beginning in June 2000, and the results were reported in an Appendix to
the Health Consultation titled, “Evaluation of Environmental Data Collected in 2000, Abby
Street/Hickory Woods Subdivision,” dated April 30, 2001. (See Attachment 1 for a copy of this
2001 report, “Summary of Hickory Woods Subdivision Exposure Survey Responses.”)
As described in the 2001 Report (Attachment 1), NYS DOH researchers evaluated the pattern of
frequently reported health conditions and symptoms by comparing them to national data from the
National Health Interview Survey, which collects information about reported health conditions
from a random sample of United States households (1). This process of comparison was used to
evaluate whether there were any obviously unusual patterns of health problems. The results of
the evaluation suggested that there might be more thyroid conditions, described as
hypothyroidism or underactive thyroid, among the Hickory Woods residents participating in the
survey than among the general population.
In response, the 2001 Health Consultation recommended that additional information be gathered
about thyroid problems reported in the Exposure Survey. The public health action plan included
in the Health Consultation stated that NYS DOH would follow up on the thyroid conditions
reported among the people who responded to the survey and that findings would be shared with
residents when follow-up activities were concluded.
DISCUSSION
A. Additional Information about the Exposure Survey conducted in 2000
For the Exposure Survey conducted in the summer of 2000, questionnaires were sent to 78
households in the Hickory Woods sub-division. Survey responses were collected from a total of
55 of these 78 households (71%). Forty-one households (53%) were contacted and interviewed
by telephone, 14 (18%) filled out and returned the survey themselves, and 23 (29%) could not be
reached after repeated attempts via telephone and a second mailing of the survey.
The neighborhood is a mix of older and newer homes. The older homes were built from 1810 to
1930, while the newer homes were built since 1989. Among the responding households, 40% of
the completed surveys were from homes built prior to 1989, while 60% were from homes built in
1989 or later. Of the non-responding households, 43% lived in homes built prior to 1989, and
57% lived in homes built in 1989 or later.
Information was collected for 201 residents, including 96 (48%) males and 105 (52%) females.
The age distribution of the residents was as follows: 45 (22%) were 0-12 years, 19 (9%) were
13-19 years, 54 (27%) were 20-39 years, 52 (26%) were 40-59 years, 26 (13%) were 60+ years,
and 5 (2%) were age unknown. The average length of residence was 10.1 years. The range was
from 1 month to 85 years. In homes built before 1989, the average length of residence was 16.0
years with a range from 1 month to 85 years. In homes built in 1989 or later, the average length
of residence was 5.5 years with a range from 2 months to 11 years.
The survey’s primary purpose was to collect information on potential exposures. Therefore, the
survey did not gather comprehensive information on health conditions and risk factors for
disease as would be done for a health study. The survey asked open-ended questions about
recurring symptoms, chronic conditions, and serious conditions. The survey did not collect
information about occupational history, tobacco or alcohol use, or other risk factors for disease,
such as family medical history, that would be evaluated in a comprehensive health study. The
exposure survey was not designed to show whether there was evidence for a link between
potential exposures and health problems in the community. Based on the limitations of the
survey’s methods, the results could not show whether or not particular health problems are
known to be elevated in the Hickory Woods community.
The original Exposure Survey Summary pointed out that it was important to note differences in
methods and circumstances between the NHIS Survey and the Hickory Woods Exposure Survey
that could affect the validity of this comparison. For example, the NHIS Survey results were
based on a random sample of U.S. households. Among the households targeted to be
interviewed, 94% were eventually reached and agreed to be interviewed. The Hickory Woods
Survey was conducted in a community with heightened awareness and concern about
environmental health issues, and a response rate of 66% of the targeted households was
achieved. With a lower response rate there is the possibility that the households who chose to
respond to the Exposure Survey may not be representative of the community as a whole. A
particular concern was that those responding could be households with more health problems or
with particular types of health problems.
Another limitation was that people in Hickory Woods, because of knowledge about
environmental issues, might have better recall about household members’ health conditions than
the general population responding to the National Health Interview Survey. Both the Hickory
Woods Exposure Survey and the National Health Interview Survey asked people to report on
chronic conditions they have. Neither survey limited responses to conditions diagnosed by
health providers. But the National Health Interview Survey listed specific conditions and asks
respondents to reply yes or no for each type of condition. The Hickory Woods Exposure Survey
asked people an open-ended question, with no lists of conditions.
As a result of this difference in survey methods, the Hickory Woods residents reported the
conditions that were most important to them or that they thought might be related to
environmental problems. As a result, the responses did not comprehensively list every health
condition or symptom among household members. In addition, the Exposure Survey responses
included various terms and non-specific terms for particular health conditions, in some cases
making it difficult to compare to the precise terminology of the National Health Interview
Survey. Despite such differences, a qualitative comparison could help to identify any unusual
patterns of health problems from the Exposure Survey that may require further consideration.
Table 1 of Attachment 1 lists selected chronic conditions among the 18 most frequently reported
by the general U.S. population in the NHIS survey. (The five conditions left off this listing were
not reported by Hickory Woods residents, and include such things as bursitis and ingrown nails).
Many of the conditions reported by Hickory Woods residents (Table 2 of Attachment 1) such as
chronic sinusitis, hay fever, asthma, bronchitis, migraine headaches and diabetes are among the
most frequently reported chronic conditions in the U.S. population. Comparison between the
rank ordering and frequency of occurrence of conditions on the two lists suggested that there
may be more skin rashes and thyroid conditions among the Hickory Woods group than among
the general population.
Acknowledging the limitations of the data and differences between the two sets of data, some
Hickory Woods residents’ reports of skin rashes may not be equivalent in severity to the
“dermatitis” category, but may fall into the “trouble with dry itching skin” category, also
reported in the National Health Interview Survey. The reported thyroid conditions, however,
appear to be appropriate for comparison with the NHIS category, “goiter or other disorders of the
thyroid.”
According to the information provided by residents for the survey, these thyroid conditions were
reported among residents who lived in Hickory Woods for a minimum of five years, maximum
of 22 years, and on average, ten years. Almost all of these reported cases were described as
hypothyroidism or underactive thyroid, which is the most frequently diagnosed thyroid condition
in the general population. Among the ten Hickory Woods residents reporting thyroid problems,
seven were female, and six were under age 45. Thyroid problems are diagnosed approximately
five times more frequently among females than males, and the risk for hypothyroid problems
increases with age, particularly after age 40. Among the four residents with thyroid problems
who were 45 years of age or older, only one was over age 65.
Because of the limitations, described above, associated with the Exposure Survey methods, the
results can not show whether or not thyroid or other health problems were elevated in the
community. The report concluded that the results suggested that there might be more thyroid
conditions, described as hypothyroidism or underactive thyroid, among the Hickory Woods
residents participating in the survey than among the general population. In response to this
finding, the 2001 Health Consultation recommended that additional information be gathered
about the reported thyroid conditions.
B. Thyroid Condition Follow-up Plan
In response to the finding suggesting a possible elevation of thyroid conditions among Hickory
Woods residents, NYS DOH stated in the Exposure Survey Summary that NYS DOH staff
would re-contact households where thyroid problems were reported, seek additional information
about health history, residential history, and occupational history, and request permission to seek
medical records from health care providers. By gathering additional information from
households reporting thyroid conditions, the researchers could seek potential explanations for the
thyroid problems. In addition, the information would provide more complete descriptions of the
thyroid conditions, so that the researchers could understand if the residents appeared to have
similar thyroid problems, whether the types diagnosed are relatively common or rare, and
whether there were other health problems associated with or predisposing the person to the
thyroid condition, such as diabetes. Unusual factors in common among the people with the
thyroid conditions might become evident, and might suggest whether there was a need for further
study.
The attached survey was written to be conducted by telephone in order to assess the diagnosed
thyroid condition, medical history, family medical history, residential and occupational history
from an endocrinologist. We also sought each person’s consent for us to request medical records
from their physician. (See attachments 2-7.)
C. Additional Information about Thyroid Disease Risk Factors
In the general U.S. population, thyroid problems are diagnosed approximately five times more
frequently among women than men, and rates per population of thyroid disease increase with
age, particularly after age 40. The primary cause for hypothyroidism in the U.S. is Hashimoto’s
Disease, an autoimmune condition that occurs when the body's immune system attacks the cells
in the thyroid gland, preventing it from producing enough thyroid hormone. While iodinedeficiency is a cause of thyroid disease in other areas of the world where iodine is not naturally
occurring and not available in food sources, iodine-deficiency is not expected in the U.S.
population.
Factors that indicate increased risk for Hashimoto’s Disease and hypothyroidism include a
family history of thyroid disease or a personal or family history of autoimmune, pituitary, or
endocrine disease. Examples of such diseases or conditions are diabetes, systemic lupus
erythematosus (lupus), rheumatoid arthritis, and vitiligo (loss of skin pigment). Additional risk
factors for hypothyroid disease include having given birth within the last six months, having high
cholesterol, clinical depression, trisomy 21 (Down Syndrome), having been treated for
hyperthyroidism, having treatment for cancer with x-rays of the neck or head, and taking lithium
(used to treat manic depression and depression) or amiodarone (used to treat life-threatening
abnormal heart rhythms). (2,3)
D. Follow-Up Results
NYS DOH staff attempted to contact the ten residents who had reported thyroid problems in
order to seek their participation in the follow-up. Two individuals did not wish to participate.
Additional information was gathered by telephone interviews for eight remaining individuals.
Information Corrections
Additional information gathered in the telephone interviews led to corrections for information in
the original survey. The 2000 Exposure Survey Summary reported that all the thyroid conditions
were reported to have occurred after moving to Hickory Woods. For one individual, the dates of
thyroid diagnosis and moving to Hickory Woods were misinterpreted or misreported in the
survey. The telephone interview revealed that this person had the thyroid diagnosis before
moving to Hickory Woods. Since the diagnosis preceded moving to Hickory Woods, additional
information from medical records was not sought for this person.
For a second person, additional information from a family member revealed that this person was
actually deceased five years prior to the Exposure Survey. Since the evaluation of thyroid
disease in the neighborhood was meant to address disease burden in the current population, if we
had known that this person was deceased, he/she would not have been included in the count of
ten people reporting thyroid conditions in the Hickory Woods neighborhood. Information
reported to us by the family of this person indicated that this individual had pre-existing
conditions, prior to moving into Hickory Woods, that are known to contribute to the risk for
thyroid disease. Medical records for this individual were no longer available, so this person’s
diagnosis was not confirmed by medical records.
Confirmation of Diagnoses
Another person with reported thyroid disease at the time of the exposure survey died prior to the
conduct of the follow-up survey. Medical records for the thyroid disease diagnosis and cause of
death were not available for this individual. Review of this person’s other reported health
conditions, reported in the Exposure Survey, revealed the existence of medical conditions, not
known to be related to thyroid disease, but likely to be related to cause of death. This person
reported having resided in Hickory Woods for two years prior to these diagnoses.
Consent for participation and for requesting medical records was granted for the five remaining
participants. NYS DOH requested and received medical records from these participants’ health
care providers. Medical records confirmed the diagnoses of hypothyroid conditions for all.
The original group of ten persons reporting thyroid conditions included 7 females and 3 males.
In the group of five for whom the diagnoses were confirmed, there were also more females than
males. As in the original survey, the participants were relatively young. The five remaining
participants were all under age 50 at the time of the original 2000 survey and almost all had been
diagnosed with thyroid problems in their 30’s and 40’s. There were no details related to the
specific thyroid diagnoses that appeared to be unusual. All of these individuals were diagnosed
with low thyroid function, or hypothyroidism, which is the most frequently diagnosed thyroid
condition in the population.
Residential and Occupational History
Additional information provided by the remaining participants indicated that about half lived in
homes that were built prior to 1920 and had lived in these homes for at least 15 years (15 - 27
year range) prior to diagnosis of hypothyroidism. The other half of the residents lived in homes
that were built since 1992 and had lived in these homes less than 5 years (1-4 year range) prior to
the diagnosis of hypothyroidism. There were no occupations in common among the people with
thyroid disorders. No unusual occupational exposures were reported.
Family and Personal Medical History
Medical records for the five remaining respondents showed that almost all had pre-existing risk
factors for thyroid disease. The majority had family histories of thyroid disease or family
histories of autoimmune disease including lupus and diabetes. Almost all of the individuals also
had personal medical histories that included risk factors for hypothyroidism. These factors
included diabetes, lupus, non-specified autoimmune disease, and a specific genetic condition
known to increase risk for thyroid disease.
Summary of Results
This follow-up evaluation gathered additional information to help us see if any unusual patterns
were evident among the people reporting thyroid conditions in the 2000 Exposure Survey.
Review of all available additional information about eight of the ten individuals, including
review of specific thyroid diagnostic information for five individuals, showed no unusual factors
in common among them.
Excluding the individual who was deceased seven years prior to the Exposure Survey, residential
and diagnostic information for seven individuals living in Hickory Woods in 2000 showed that
six of these individuals received diagnoses of thyroid disease after living in Hickory Woods for a
length of time ranging from one to 27 years. One of these six people was deceased prior to the
follow-up, so medical records were not available for confirming the thyroid diagnosis. Medical
records for five individuals showed that most of these individuals had family histories of thyroid
or autoimmune disease and almost all had one or more other medical conditions that contribute
to the risk for thyroid disease. A variety of these pre-disposing conditions were present,
including conditions such as diabetes and lupus.
CONCLUSIONS
1. Neither the original survey nor this follow-up can show whether or not particular health
problems are known to be elevated in the Hickory Woods community.
2. While the Exposure Survey results suggested in 2001 that there might be more thyroid
conditions among the Hickory Woods residents participating in the survey than among the
general population, this review of additional information provided by people who consented to
participate in follow-up has not indicated any unusual factors in common among the group.
3. This follow-up showed a variety of predisposing conditions for almost all of the participants
in the follow-up with thyroid conditions, and therefore suggests that further investigation,
seeking alternative explanations for these diagnoses, is not warranted.
RECOMMENDATION
No additional epidemiological investigations are recommended at this time.
REFERENCES
1. Current Estimates from the National Health Interview Survey, 1996, Vital and Health
Statistics, from the Centers for Disease Control and Prevention/National Center for Health
Statistics, Series 10, No. 200, Table 57: Number of selected reported chronic conditions per
1,000 persons, by age; United States, 1996.
2. Lymphatic Thyroiditis, Struma Lymphomatosa, IN: Wilson TD, Foster DW, eds. William’s
Textbook of Endocrinology, Philadelphia PA: WB Saunders Co; 1992:475.
3. Helfland M, Crapo LM. Screening For Thyroid Disease. Ann Intern Med, Off Ed. 1990;
112:840-9.
PREPARERS OF THE REPORT
New York State Department of Health Authors
Megan Meldrum
Research Scientist
Bureau of Environmental and Occupational Epidemiology
New York State Department of Health
Elizabeth Lewis-Michl
Research Scientist
Bureau of Environmental and Occupational Epidemiology
New York State Department of Health
Agency for Toxic Substances and Disease Registry
ATSDR Regional Representative:
Arthur Block
Regional Services
Office of the Assistant Administrator
ATSDR
ATSDR Technical Project Officer:
Greg Ulirsch
Technical Project Officer
Division of Health Assessment & Consultation
Superfund Site Assessment Branch
ATSDR
Patricia Price-Green
Epidemiologist
Epidemiology and Surveillance Branch
Division of Health Studies
ATSDR
Attachment 1:
SUMMARY OF HICKORY WOODS SUBDIVISION
EXPOSURE SURVEY RESPONSES
PREPARED BY
New York State Department of Health
Center for Environmental Health
APPENDIX C
of the Health Consultation:
Evaluation of Environmental Data Collected in 2000
Abby Street/Hickory Woods Subdivision
City of Buffalo, Erie County, New York
April 30, 2001
Prepared under a Cooperative Agreement with
U.S. Department of Health & Human Services
Public Health Service
Agency for Toxic Substances and Disease Registry
Summary of the Hickory Woods Subdivision Exposure Survey Responses
Background
In response to concerns about potential exposures and health problems in the Hickory
Woods Development in Buffalo, New York, in December of 1999, the New York State
Department of Health (NYS DOH) proposed conducting an exposure survey in the community.
The primary purpose of the survey was to gather information about the people living at each
residence, whether they had noticed or come in contact with chemical substances or unusual
materials in the subdivision, and whether they had any health concerns related to potential
environmental exposures. Staff of the Bureau of Environmental and Occupational Epidemiology
of the Center for Environmental Health developed the draft survey and worked with
representatives of the Hickory Woods Concerned Homeowners’ Association, Citizen’s
Environmental Coalition and Environment and Society Institute of the University at Buffalo to
revise the survey, draft a cover letter about the purpose of the survey, and develop a plan for
administering the survey. NYS DOH sent copies of the survey to residents prior to contacting
each household by telephone. (See Attachments for the exposure survey questionnaire and cover
letter.)
The list of names and addresses for mailing the survey was developed from lists compiled
by NYS DOH and the United States Environmental Protection Agency (EPA). Using a map
showing the boundaries for the area where EPA was planning to conduct residential soil
sampling and aerial photographs to help locate buildings, addresses were identified for eightytwo households in the study area. In addition to information from existing lists, property
ownership information files and telephone directories were used to find names and telephone
numbers associated with each address. Additional telephone numbers were provided by the
Homeowner’s Assocation.
On June 22, 2000, the telephone survey questionnaire and cover letter explaining the
survey process were mailed to residents of the Hickory Woods Subdivision. On June 28, 2000,
representatives from the Bureau of Environmental and Occupational Epidemiology of NYS
DOH began conducting the telephone survey. On August 31, 2000, a second mailing of the
telephone survey was sent to residents who had not yet completed the survey.
Survey Response Summary
Response Rates and Demographic Characteristics
Survey questionnaires were sent to 78 households. Survey responses were collected from
a total of 55 of these 78 households (71%). Forty-one households (53%) were contacted and
interviewed by telephone, 14 (18%) filled out and returned the survey themselves, and 23 (29%)
could not be reached after repeated attempts via telephone and a second mailing of the survey.
One former resident of a household address already included in the EPA’s sampling study area
requested a survey, and one resident whose residence, on the east side of Germania Street, was
originally outside the study area, but later added to the list for sampling, requested and
completed a survey. The two additional households were interviewed by telephone and included
in the study for a total of 57 households, representing 56 unique addresses.
The neighborhood is a mix of older and newer homes. The older homes were built from
1810 to 1930, while the newer homes were built since 1989. For the 57 responding households,
23 (40%) completed surveys were from homes built prior to 1989, while 34 (60%) were from
homes built in 1989 or later. Of the 23 non-responding households, 10 (43%) were homes built
prior to 1989, and 13 (57%) were homes built in 1989 or later.
Information was collected for 201 residents, including 96 (48%) males and 105 (52%)
females. The age distribution of the residents was as follows: 45 (22%) were 0-12 years, 19
(9%) were 13-19 years, 54 (27%) were 20-39 years, 52 (26%) were 40-59 years, 26 (13%) were
60+ years, and 5 (2%) were age unknown. The average length of residence was 10.1 years. The
range was from 1 month to 85 years. In homes built before 1989, the average length of residence
was 16.0 years with a range from 1 month to 85 years. In homes built in 1989 or later, the
average length of residence was 5.5 years with a range from 2 months to 11 years.
Potential Environmental Exposures
Fifty-six (98%) households reported having a basement. Thirty-three households
reported that the basement becomes wet at times. Forty of the houses with basements have a
sump pump, and 22 of these sump pumps are described as running at least daily. Nineteen
households reported using the basement as part of the living space.
Thirty-four (60%) households reported that children regularly spend time in the yard.
The activities included playing, sports, picnics and cook outs, using child pools and sprinklers,
and helping adults with yard and construction work. Sixteen (28%) of the homes have a swing
set or play area in the yard with 12 (21%) reporting exposed soil in these areas. Thirty-two
(56%) households reported exposed soil in other areas of the property. Twenty-three (40%)
reported children playing on vacant lots in the neighborhood.
Forty-one (72%) households reported that family members regularly spend time outdoors
in the subdivision, and 45 (79%) reported spending time outdoors in the past. Activities included
walking, bike riding, dog walking, playing at the playground, delivering papers, and sledding.
Thirty-one (55%) have a fruit or vegetable garden on the property, 10 (18%) have a fruit
or vegetable garden elsewhere in Hickory Woods, and 34 (61%) eat fruits or vegetables from a
garden anywhere in Hickory Woods. Forty-three (77%) of homes have a flower garden, 54
(96%) work on their lawns, 40 (71%) do other landscaping work, and 32 (57%) do construction
work on the property. The landscaping and construction activities included installing fences,
decks, sheds, additions, swing sets, pools, patios, walkways, and planting shrubs and trees.
Other activities that involved digging below the soil surface ranged from a depth of 5 inches to 4
feet.
Thirty-five (61%) reported having pets that track in dirt or other substances from the
outside. The pets play or get walked in the yard, berm, streets, and vacant lots. Twenty-eight
(49%) have pets that often dig holes or have other habits or characteristics that contribute to
bringing dirt or other substances into the home.
Thirty-three (58%) households reported noticing chemical substances, unusual materials,
or discolored soil on the property, and 16 (28%) reported that children play in the area. There
were 22 (39%) reports of dark, black or cindery soil, 16 (28%) reports of debris in soil, 8(14%)
reports of ash-like substances in soil, and 7 (13%) reports of orange “goo” near sump pumps or
sewers. The debris included coal-like substances, steel, pipe, bricks, asphalt, building materials,
glass, and tires. Twenty-four (71%) of the homes built in 1989 or later reported noticing
chemical substances on their property versus 9 (39%) of the homes built prior to 1989. The most
commonly reported substance in both newer and older homes was the dark, black or cindery soil.
Thirty-three (58%) households reported noticing chemical substances, unusual materials,
or discolored soil elsewhere in Hickory Woods, and 21 (37%) have seen children playing in the
area. Eighteen (32%) households described the standing water with strange colors and odors
near the berm, nine (16%) reported similar puddles of standing water elsewhere in Hickory
Woods, three (5%) reported coke-like debris, two (4%) reported an odor like mothballs, one
reported orange-colored, standing water in a new basement, and one reported a yellow and green,
thick substance where the gas line entered a newly constructed home.
Twenty-seven (47%) households reported at least one family member coming in contact
with these chemical substances. Fifteen (26%) homes reported family members being exposed
when gardening or doing yard work, seven (12%) while walking or walking the dog in the
subdivision, five (9%) while playing in the area, four (7%) while installing a fence or performing
home improvements, and one when the basement flooded. Sixty-seven (33%) residents were
listed as coming into contact with the substances. In homes built prior to 1989, 10 (43%) of
households reported a member coming in contact with unusual chemical substances. In newer
homes, 17 (50%) of households reported a family member coming in contact with the unusual
substances.
Twelve (21%) households reported that the vehicle traffic on the street is very light, 35
(63%) reported average traffic for a residential area, and nine (16%) reported constant heavy
traffic. Twelve (21%) reported living near businesses where cars are often parked, and two (4%)
reported cars left idling for long periods. Thirty-one (54%) reported living near businesses
where trucks are often parked, and 23 (40%) reported trucks left idling for long periods.
Forty-seven (83%) have noticed unusual types or amounts of dust in the outdoor air near
the residence currently or in the past. Thirty-three (58%) said the dust varies with the season, 24
(42%) said the dust varied with temperature, and 37 (65%) said the dust varied with wind
conditions. Thirty-two (56%) reported noticing dust currently. The most frequently mentioned
time periods that unusual amounts of dust were noticed were during the construction of new
homes, when trucks drove by, when street was unpaved, during remediation of lots, and during
hot or windy days. The dust was usually described as black.
Reported Health Concerns
When household respondents were asked about health concerns, 48 (84%) reported a
variety of health problems among family members. These health problems were reported for
130 (65%) residents. The open-ended health concern question asked people to report health
problems they thought were important. Residents were asked to report about long-term or
chronic health problems, continuing symptoms that concerned them although they may not have
reported them to a physician, and serious health problems, such as a diagnosis of cancer.
Respiratory tract and ear/nose/throat symptoms and conditions, including asthma,
bronchitis, sinusitis, bloody noses, persistent earaches, frequent cough and other cold symptoms
were reported by 70 (35%) residents. 37 (18%) residents reported symptoms in a broad
category of “general” symptoms including joint and muscle aches, headaches, migraines, fatigue,
weakness, anorexia. Table 1 lists twelve specific chronic conditions reported by residents and
shows the number of residents who reported each condition. Chronic sinus problems led the list
with 23 residents reporting sinus conditions, including chronic sinus infections. Asthma, skin
rashes, and hay fever or other allergies, thyroid problems and heart disease were the next five
most frequently reported conditions and symptoms. Ten residents reported having been
diagnosed with thyroid problems, and almost all described the condition as underactive thyroid
or hypothyroidism. Some respondents reported links between symptoms and specific activities,
such as rashes that developed in household members directly after handling soil in the yard.
Some respondents also reported that members of their families began experiencing many more
health problems after moving to Hickory Woods.
Some reports of health conditions gave descriptions using terms such as tumor, polyp, or
growth. These conditions were not counted as reports of cancer. If the term “cancer” was used,
or if the reported condition is a type of cancer (melanoma or multiple myeloma, for example),
the condition was classified as cancer for this evaluation. (New York State maintains a Cancer
Registry, and NYS law mandates that all cancers, excluding non-invasive skin cancers, must be
reported by health care providers, hospitals, and clinics to the Registry. However, for this
evaluation, the Registry was not used for confirming the reported cancers or gathering additional
information on specific type of cancer.) Eleven cases of cancer were reported among residents
responding to the survey. For one reported case of cancer, type of cancer was not reported and
the age at diagnosis and length of residence of the person, now deceased, was not reported. For
one other reported case of cancer, the age at diagnosis of the person was not reported. Among
the nine other reported cases of cancer, six were among people age 60 or older and three were
among people in the age group, 30 through 59. Length of residence in Hickory Woods among
ten of the 11 reported cancer cases ranged from less than one year to 76 years, with four people
reporting length of residence of ten years or more and six reporting fewer than ten years’
residence. The ten reported types of cancer included nine different types of cancer.
Each household was given the opportunity to make comments about the environmental
issues in the neighborhood. A specific question asked, “Would you like to comment on what
you would like to see done about the contamination issues in the neighborhood?” Five
households did not comment, and five of the comments recorded could not be classified in the
following categories. Respondents from 14 households stated they wanted to be relocated and
have their homes bought out. Seven wanted to be relocated if the sampling showed ongoing
health risks. Thirteen households wanted the neighborhood environmental problems to be
cleaned up. Eleven households stated that the situation was overblown, and two stated they were
waiting for the sampling results before forming an opinion about what needed to be done.
Some residents expressed the opinion that people should be relocated temporarily
during clean-up. A frequent concern in these comments was that clean-up activities could lead to
additional exposures to PAHs. Most residents’ comments emphasized their primary concern
with protecting their families’ health. Additional concerns included property values, getting
accurate information, and the actions of public agencies and officials.
Residents brought up concerns about the LTV inactive hazardous waste site, bordering
Hickory Woods on Abby Street. Residents also mentioned concerns about potential exposures
from operating facilities such as Buffalo Color, Buffalo China and Bethlehem Steel’s coke
furnace. Some residents reported odors they believe came from Buffalo Color. Some long-term
residents reported that levels of dust and ash used to be much more noticeable when the LTV
facility, formerly Republic Steel, and Donner-Hanna Coke were in operation. Many owners of
older homes described the black dust that had accumulated within the walls during the years that
these plants were operating.
Discussion and Conclusions
Potential Environmental Exposures
One goal of the exposure survey was to gather information related to possible routes of
exposure to environmental contaminants. By participating in the survey, residents had an
opportunity to inform NYS DOH researchers about the range of activities that may have led to
exposure to chemicals, particularly in soil. The survey results show that about 75% of Hickory
Woods households reported having a fruit or vegetable garden, about 75% reported having
flower gardens, and almost 75% reported they did landscaping work. Members of more than
50% of the households reported having done construction work on their property.
Approximately 50% of the households reported that family members had come in contact with
unusual chemical substances. More than 60% of households reported having pets that track in
dirt or other substances from the outside. The Exposure Survey respondents reported having
many more gardens than were reported to EPA and NYS DOH field staff. The reason for the
difference may be that residents, in responses to the Exposure Survey, reported gardens they had
currently or in the past, while for the EPA and NYS DOH field staff, residents only reported
currently active gardens. Most responses to the Exposure Survey did not include a timeframe for
the garden. Of the ten questionnaire responses that included a timeframe, three reported gardens
continuing in the year 2000, three reported gardens only through 1999, and the others reported
gardening that ended in earlier years.
Reported Health Problems
Another goal of the exposure survey was to provide residents with an opportunity to
report problems that might suggest unusual patterns of illness in the neighborhood, if such
patterns existed. This information would be helpful for planning an appropriate health study, if
the sampling results indicated that such a study was warranted. The survey asked open-ended
questions about recurring symptoms, chronic conditions, and serious conditions. The survey did
not collect information about occupational history, tobacco or alcohol use, or other risk factors
for disease, such as family medical history, that would be evaluated in a comprehensive health
study.
The researchers evaluated the pattern of frequently reported health conditions and
symptoms by comparing the pattern of frequently reported conditions to national data from the
National Health Interview Survey, which collects information about reported health conditions
from a random sample of United States households. This process of comparison was used to
evaluate whether there were any obviously unusual patterns of health problems. It is important
to note beforehand, however, differences in methods and circumstances between the NHIS
Survey and the Hickory Woods Exposure Survey that may affect the validity of this comparison.
For example, the NHIS Survey results are based on a random sample of U.S. households.
Among the households targeted to be interviewed, 94% were eventually reached and agreed to
be interviewed. The Hickory Woods Survey was conducted in a community with heightened
awareness and concern about environmental health issues, and a response rate of 66% of the
targeted households was achieved. With a lower response rate there is the possibility that the
households who chose to respond to the Exposure Survey may not be representative of the
community as a whole. A particular concern is that those responding may be households with
more health problems or with particular types of health problems. Another limitation is that
people in Hickory Woods, because of knowledge about environmental issues, may have better
recall about household members’ health conditions than the general population responding to the
National Health Interview Survey. The exposure survey was not designed for conclusively
identifying whether there were excesses of symptoms or disease in the study area.
Both the Hickory Woods Exposure Survey and the National Health Interview Survey
asked people to report on chronic conditions they have. Neither survey limited responses to
conditions diagnosed by health providers. But the National Health Interview Survey listed
specific conditions and asks respondents to reply yes or no for each type of condition. The
Hickory Woods Exposure Survey asked people an open-ended question, with no lists of
conditions. As a result of this difference in survey methods, the Hickory Woods residents
reported the conditions that were most important to them or that they thought might be related to
environmental problems. As a result, the responses did not comprehensively list every health
condition or symptom among household members. In addition, the Exposure Survey responses
included various terms and non-specific terms for particular health conditions, in some cases
making it difficult to compare to the precise terminology of the National Health Interview
Survey. Despite such differences, a qualitative comparison may help to identify any unusual
patterns of health problems from the Exposure Survey that may require further consideration.
Table 2 lists selected chronic conditions among the 18 most frequently reported by the
general U.S. population in the NHIS survey. (The five conditions left off this listing were not
reported by Hickory Woods residents, and include such things as bursitis and ingrown nails).
Many of the conditions reported by Hickory Woods residents such as chronic sinusitis, hay fever,
asthma, bronchitis, and migraine headaches and diabetes are among the most frequently reported
chronic conditions in the U.S. population. Comparison between the rank ordering and frequency
of occurrence of conditions on the two lists, suggests that there may be more skin rashes and
thyroid conditions among the Hickory Woods group than among the general population.
Acknowledging the limitations of the data and differences between the two sets of data, some
Hickory Woods residents’ reports of skin rashes may not be equivalent in severity to the
“dermatitis” category, but may fall into the “trouble with dry itching skin” category, also
reported in the National Health Interview Survey. The reported thyroid conditions, however,
appear to be appropriate for comparison with the NHIS category, “goiter or other disorders of the
thyroid.”
Thyroid Conditions: In the general U.S. population, thyroid problems are diagnosed
three to four times more frequently among women than men, and rates per population of thyroid
disease increase with age. Among the ten Hickory Woods residents reporting thyroid problems,
seven were female, and six were under age 45. Among the four residents with thyroid problems
who were 45 years of age or older, only one was over age 65. These thyroid conditions were
reported among residents who lived in Hickory Woods for a minimum of five years, maximum
of 22 years, and on average, ten years. Almost all of these reported cases were described as
hypothyroidism or underactive thyroid.
Cancer: This evaluation of the reported cancers is based on the approach used by NYS
DOH to review cancer cases in small geographic areas. Characteristics of the cases, such as type
of cancer diagnosed, age at diagnosis and year of diagnosis are examined to look for any unusual
patterns. These patterns include: (1) several cases of the same type of cancer; (2) two or more
cases of a rare cancer type; (3) several cases in an unusual or unexpected age group; (4) a
clustering of the same cancer type by year of diagnosis; and (5) adequate latency period (time
between first potential exposure to an environmental hazard in the community or workplace and
development of cancer). The finding of any of these patterns suggests the possibility that cases
may share a common cause and, therefore, may provide a basis for further investigation.
The distribution of types of cancer among Hickory Woods residents reporting cases of
cancer did not point to an unusual pattern of cancer incidence. The ten reported types of cancer
(one report did not specify type) for residents of Hickory Woods involved nine different types of
cancer. The age distribution of the cases did not appear unusual. Most cases were over age 60 at
diagnosis. Because community surveys may miss diagnoses of cancer among people in the
community, the reported cases cannot be assumed to represent all the cancer cases diagnosed in
recent years in the area.
More information about cancer incidence in the Hickory Woods area will soon be
available in a ZIP code screening evaluation being conducted by the NYS Cancer Surveillance
Program. As part of an evaluation of cancer incidence in the area near Bethlehem Steel in
Lackawanna, cancer incidence is being evaluated for ZIP code 14220 where Hickory Woods is
located. Although Hickory Woods comprises a very small part of this ZIP code, the results of
this evaluation will be checked to see if they are consistent with the interpretation of selfreported cancers presented above.
A few families in the study area have experienced particularly severe and difficult
health problems, not specifically described here to protect individual privacy. While it may not
be possible for a health study of this relatively small community to draw conclusions about
whether environmental exposures are linked to relatively rare health problems, individual health
problems are still important. To date, our review of the scientific research literature on some of
these specific health problems reported by Hickory Woods residents has not provided evidence
for direct links to environmental exposures. Continued attention to the literature, as well as to
any additional information that residents wish to provide, may be useful for developing
suggestions for additional research.
Overall Conclusion
The exposure survey has identified a variety of pathways for potential exposure to
residential soils at various depths and suggested a variety of health problems that are of
particular concern to this community. The exposure survey was not designed to show whether
there was evidence for a link between potential exposures and health problems in the
community. Based on the limitations of the survey’s methods, the results cannot show
conclusively whether or not particular health problems are known to be elevated in the Hickory
Woods community.
Recommendation
To follow-up on the thyroid conditions reported among the people who responded to the
survey, NYS DOH staff will re-contact households where thyroid problems were reported, seek
additional information about health history, residential history, and occupational history, and
request permission to seek medical records from health care providers. By gathering additional
information from households reporting thyroid conditions, the researchers can seek potential
explanations for the thyroid problems. In addition, the information will provide more complete
descriptions of the thyroid conditions, so that the researchers can understand if the residents
appear to have similar thyroid problems, whether the types diagnosed are relatively common or
rare, and whether there are other health problems associated with or predisposing the person to
the thyroid condition, such as diabetes. Factors in common among the people with the thyroid
conditions may become evident, and may suggest whether there is a need for further study.
Table 1. Listing of chronic conditions reported in exposure survey in rank order by
number of individuals reporting (*Numbers smaller than five not shown.)
Chronic Condition
Number Reported
Chronic Sinus Problems
23
Asthma
18
Skin Rashes
16
Hay Fever or Allergic Rhinitis
15
Goiter or Other Thyroid Disease
10
Heart Disease
8
Diabetes
5
Frequent Indigestion
5
Arthritis
*
Chronic Bronchitis
*
Migraine Headaches
*
High Blood Pressure
*
Table 2. Listing of selected chronic conditions in the general U.S. population in rank order
by rate per 1,000 population
rate per 1,000 (all ages)
127.3
125.8
107.1
89.8
78.2
55.2
53.5
43.7
31.2
28.9
25.1
24.3
17.4
Arthritis
Chronic sinusitis
High blood pressure
Hay fever or allergic rhinitis without asthma
Heart disease
Asthma
Chronic bronchitis
Migraine headaches
Dermatitis
Diabetes
Trouble with Dry Itching Skin
Frequent indigestion
Goiter or other thyroid disease
Source: Current Estimates from the National Health Interview Survey, 1996, Vital and Health
Statistics, from the Centers for Disease Control and Prevention/National Center for Health
Statistics, Series 10, No. 200, Table 57: Number of selected reported chronic conditions per
1,000 persons, by age; United States, 1996.
Attachment 2: Introduction Letter
Name
Address
Date
Dear:
In May of 2001 The New York State Department of Health (NYS DOH) Center for
Environmental Health completed its Health Consultation for the Abby Street/Hickory Woods
Subdivision, An appendix to the Health Consultation summarized the responses to our survey
which consisted of questions about exposures and health. The results of the NYSDOH exposure
survey suggest that there may be more thyroid conditions, described as hypothyroidism or under
active thyroid, among the Hickory Woods residents who participated in the survey than among
the general population. Additional information is needed to help NYSDOH better understand the
thyroid conditions that have been reported by the Hickory Woods residents.
We are following up on the thyroid conditions reported among the people who responded to our
survey. We are contacting you because you identified yourself or a member of your family as
having a thyroid condition in the survey.
As part of this follow up we would like to complete a short telephone interview with you. The
interview normally takes only about 10 minutes. During this interview we will gather additional
information about health history, residential history, and occupational history. This additional
information will provide more complete descriptions of the thyroid conditions, so that the
researchers can understand if the residents appear to have similar thyroid problems, whether the
types diagnosed are relatively common or rare, and whether there are other health problems
associated with or predisposing the person to the thyroid condition, such as diabetes. Factors in
common among the people with thyroid conditions may become evident, and may suggest
whether there is a need for further study.
Ms Lorraine Benton will be calling you within the next week to discuss your interest in this
project. The telephone number that we have listed for you is _____________. If this telephone
number is incorrect or there is a more convenient time for us to call, please call Lorraine Benton
at 1-800-458-1158 extension 27950.
If you have any questions or do not wish to be contacted, please call Lorraine Benton at 1-800458-1158 extension 27950.
Thank you in advance for your help.
Sincerely,
Dr. Elizabeth Lewis-Michl
Attachment 3:
Telephone Protocol
If you get a person:
Hello, this is _______from the Center for Environmental Health. May I please speak
with_______. (if the subject is there continue with this part if not see phone message protocol).
Mr./Mrs. ______, I am calling in regards to a letter that I sent to you recently. Do you have a
few moments to talk? If no – when is a better time for me to call?
If yes – Thank you. I am calling to see if you might be willing to help us with the continued
research that is being done on thyroid conditions in your community. I am calling you because
you had responded in our first mail in survey that you or a household member had been
diagnosed with thyroid disease. Is that correct? What I would like to do, if you have about 10
minutes, is to complete the short telephone interview part of this project. Would now be a good
time to do that? (if no – then when is a better time?).
If you have to leave a message (machine or household member other than subject):
Hello, this message is for Mr. / Mrs. _________. _______ this is _________from the
Center for Environmental Health. I am calling in regards to a letter I sent to you about one week
ago and I was hoping to have a moment or two to speak with you. If you could give me a call
back at 1-800-458-1158 extension 27950 and just let me know what would be a better time for
me to call I would greatly appreciate it. Thank you.
(Note: if you are speaking to a person you can just ask them when would be a better time to try
to reach the study subject)
If this is the third message that we have left with no response, we may add a line that they could
also call 1-800-458-1158 X 27950 and leave a message that they are not interested in
participating in the research project.
At the end of the interview:
Thank you for taking the time to complete this interview with me. The next step in our
investigation is to review the medical records of people participating in this project. The reason
for doing this is to ensure that we have complete information on the types of thyroid conditions
that have been reported in your community. Once we have this information along with the
valuable information you have just provided we will be better able to evaluate whether the
thyroid conditions in the community are related. In order for us to be able to review the medical
records we need you to complete a consent form, that I will send to you, and then return this
form to me in a stamped addressed envelope that I will also provide. This consent form needs to
be completed for yourself and name of each household member for whom thyroid conditions
were reported. I will send you one form for each of your physicians. How many physicians
have helped to diagnose or treat your thyroid condition? All the information we collect for
this project will be kept strictly confidential.
May I send out the consent form for you to review?
Thank you again and please feel free to call me with any questions you may have regarding this
project.
Attachment 4: Thank-you letter to participants
Name
Address
Date
Dear:
Thank you for completing the telephone interview with me on date of interview. As we discussed
at that time, I am sending you the medical release forms. Please complete one form for each
physician that has helped diagnose or treat your thyroid condition. Please sign each medical
release consent form. Then please return these forms to me in the enclosed self addressed
stamped envelope.
If you have any questions please call me at 1-800-458-1158 extension 27950.
Thank you again for joining us in this project.
Sincerely,
Lorraine Benton
Attachment 5: Consent to release medical information
New York State Department of Health
Center for Environmental Health
Bureau of Environmental & Occupational Epidemiology
CONSENT TO RELEASE INFORMATION
I consent to participate in the follow-up evaluation and agree to the release of my medical
records concerning my thyroid diagnosis, treatment and follow-up care, to the project
investigators at the New York State Department of Health.
PATIENT SIGNATURE
PATIENT’S NAME
(please print)
DATE
STREET ADDRESS
CITY, STATE, ZIP
TELEPHONE NUMBER :
HOME:
(
WORK: (optional)
)
(
)
HEALTH CARE PROVIDER:
NAME
First Name
PRACTICE NAME
STREET ADDRESS
CITY, STATE, ZIP
TELEPHONE NUMBER (
)
Please return to:
Pat Steen
NYS Department of Health
Flanigan Square, Room 200
547 River Street
Troy, NY 12180-2216
(518) 402-7950
Last Name
Attachment 6: Letter to health care provider
DATE
MD Name
Address
City, State
Dear :
Please find enclosed a consent form for the release of medical information from your patient,
Subject name. Ms/Mr. Last Name is participating in a follow-up investigation that is being
conducted by the New York State Department of Health, Bureau of Environmental Health. As
part of this investigation we are following up on Name’s history of thyroid disease. Name
indicated that he/she had been diagnosed with Thyroid Condition in Year.
Please send any information pertaining to Name’s diagnosis or treatment of Thyroid Condition
to:
Pat Steen
NYS Department of Health
Flanigan Square, Room 200
547 River Street
Troy, NY 12180-2216
If you have any questions, please call Lorraine Benton at 518-402-7950.
Thank you in advance for your assistance.
Sincerely,
Elizabeth L. Lewis-Michl, Ph. D., Chief
Community Exposure Research Section
Bureau of Environmental and Occupational Epidemiology
Attachment 7: Participant Interview Questions
Assigned ID:
Sex
Date
Time
Interviewer
First I have a few general questions.
1. What is your age?
2.What is your date of birth?
3. How tall are you?
4. How much do you weigh?
5. When did you move to your current residence (MMYY)
6. How long have you lived at your current residence?
7. Have you ever lived at another residence in hickory woods?
If yes: 7a. How many other residences in hickory woods?
7b. When did you move into the first residence?
7c. What was the address of this residence?
7d. How long did you live in this residence?
7e. When did you move out of this residence?
7f. When did you move into the second residence?
7g. How long did you live in this residence?
7h. What was the address of this residence?
7i. When did you move out of this residence?
7j. When did you move into the third residence?
7k. What was the address of this residence?
7l. How long did you live in this residence?
7m. When did you move out of this residence?
7n. When did you move into the fourth residence?
7o. What was the address of this residence?
7p. How long did you live in this residence?
7q. When did you move out of this residence?
7r. When did you move into the fifth residence?
7s. What was the address of this residence?
7t. How long did you live in this residence?
7u. When did you move out of this residence?
8. Are you currently employed?
If yes: 8a. What is your job?
8b. For what type of business or industry do you work?
8c. How long have you had this job?
9. Have you ever had a job where you were exposed to chemotherapeutic agents?
If yes: 9a. What were you exposed to?
9b. What was your job?
9c. When did you begin this job?(year)
9e. How long did you do this type of work?
10. Have you ever had a job where you were exposed to x-rays, microwaves or some other form
of
radiation?
If yes: 10a. What were you exposed to?
10b. What was your job?
10c. When did you begin this job? (year)
10d. How long did you do this type of work?
Now I have some questions about cigarette smoking.
11. Have you ever smoked regularly, by that I mean one cigarette a day or seven in a week?
If yes: 11a. Did you smoke in the past month?
11b. How many cigarettes did you smoke?
11c. How old were you when you first began smoking?
11d. During the time you were smoking, how many cigarettes did you usually smoke?
11e. How old were you when you last smoked?
11f. Between the ages of _________ and _______ did you ever stop smoking?
If yes: 11g. How many times did you stop?
11h. Thinking of the first (second, third, …)time you stopped, how long did you
stop?
(Ask for each time stopped) Total Duration:
The next few questions pertain to some medical conditions.
12. How many different doctors do you currently have?
Has a doctor or Thyroid
other healthcare Disease
professional
13.
ever said you
have
a. What type of
___ do you
have?
b. What tests
were done to
diagnose ____?
c. How old
were you when
you were first
diagnosed?
d. What year
were you first
diagnosed?
e. Do you
currently
have_____?
f. Are you
currently being
treated for ___?
g. If yes: what
medication or
treatment
Diabetes Lupus
14.
15.
Rheumatoid Addison’s
Arthritis
Disease
16.
17.
Vitiligo
Anemia
18.
19.
I have some questions about your family history. These questions are in regards to your
immediate family that do NOT currently reside in your house with you.
Has a doctor or Thyroid Diabetes Lupus Rheumatoid Addison’s Vitiligo Anemia
other healthcare Disease
Arthritis
Disease
20.
21.
22.
23.
24.
25.
26.
professional
ever said a
member of
your family had
a. What is their
relationship to
you?
b. What type
of ___ does/did
_____ have?
c. What tests
were done to
diagnose ____?
d. How old
was ____ when
he/she was first
diagnosed?
e. What year
was he/she first
diagnosed?
f. Does he/she
currently
have_____?
g. Is he/she
currently being
treated for ___?
h. If yes: what
medication or
treatment